I welcome Professor Barry Bresnihan, chairman of Arthritis Ireland; Dr. Robert Coughlan, consultant rheumatologist at Merlin Park Hospital, Galway; Dr. Michael Molloy, consultant rheumatologist at University College Hospital, Cork; Dr. Gaye Cunanne, consultant rheumatologist at St. James's Hospital, Dublin; Professor Oliver Fitzgerald, consultant rheumatologist at St. Vincent's Hospital, Dublin; Ms Mary Healy, chairperson of the Mayo branch of Arthritis Ireland; Ms Patricia Minnock, chairperson, Irish Rheumatology Health Professionals Society and advanced nurse practitioner in rheumatology, and Dr. Paul O'Connell, consultant rheumatologist at Beaumont Hospital, Dublin and chairman of the Irish Society of Rheumatology. I ask the delegation to begin its presentation on the present and future needs of the rheumatology services.
Rheumatology Services: Presentation.
Professor Barry Bresnihan
I thank the committee for inviting us. Our presentation addresses the requirements of the rheumatology service and the development of academic rheumatology.
We do not know exactly how many people in Ireland have arthritis. However, there are figures available from the UK which are based on detailed epidemiological studies. If one extrapolates from those figures, the suggestion is that every year approximately 400,000 people in Ireland consult their doctor with symptoms related to arthritis. Almost one third of women and one quarter of men will complain of arthritis or joint pain to their general practitioner. The condition is more common in older people. For example, 52% of those over 55 will develop arthritis. However, it is important to note that almost one in five of those under 55 will also present to the medical services with problems relating to arthritis.
Arthritis is a socio-economic issue. When one extrapolates from the UK data, the cost of arthritis in lost working days in Ireland is approximately €1.6 billion per annum. Arthritis accounts for the largest category of general practitioner visits. It is estimated that 30% of GP visits are for musculoskeletal disorders. Approximately 60% of people with arthritis will be treated within the primary health care system, while the remainder will require specialist management.
Rheumatology resources in Ireland are limited. There is a significant burden of ill health due to disability that is directly attributable to arthritis. Many forms of arthritis, such as rheumatoid arthritis, are associated with other major co-morbidities and with early mortality. Cardiovascular disease is one such co-morbidity. There is an approximately 40% increased risk of heart attack in patients with rheumatoid arthritis. Infection is another associated co-morbidity. Approximately one quarter of all deaths of those with rheumatoid arthritis is related to infection. Osteoporosis is a problem for people with long-standing rheumatoid arthritis and their disability can be complicated by easy fractures in older age. Malignancy is also associated with rheumatoid arthritis, as is serious peptic ulcer disease.
Rheumatology is the medical specialty concerned with the care of people with diseases of joints, bones or muscles. A typical rheumatology team is led by a rheumatologist and includes other specialists, such as specialist nurses, physiotherapists, occupational therapists, podiatrists, medical social workers and psychologists. The team also works closely with orthopaedic surgery departments. Rheumatology is a multidisciplinary service that cannot function properly without its various component parts. An inadequate rheumatology service results in critical delays in the diagnosis of common, treatable diseases and the failure to prevent disability, co-morbidity and death. It also places unnecessary strain on over-stretched primary care and emergency services. A typical rheumatology service is predominantly outpatient based and dependent on a specialist multidisciplinary team of health professionals. In general, it does not require expensive inpatient resources.
If one examines a map of Ireland, one can see that there are large areas of the country that are completely devoid of rheumatology services. There are 12 rheumatology centres in the Republic: one in Navan; five in Dublin; one in Waterford; two in Cork; one under-development in Limerick; one in Galway; and one in Manorhamilton. There are 20 consultant rheumatologists, 19 of whom have a considerable acute general internal medicine component to their work. The service is, therefore, provided by one whole-time equivalent rheumatologist per 400,000 of the population.
The British Society of Rheumatology recommends that an adequate rheumatology service consists of one whole-time equivalent consultant per 85,000 of the population. In Northern Ireland there are 15 consultant rheumatologists, only seven of whom have an acute general internal medicine component to their work, providing a ratio of one whole-time equivalent rheumatologist per 160,000 of the population. Thus there is a significant difference in service levels on either side of the Border.
Why should we develop rheumatology services? There is a window of opportunity for early diagnosis and treatment of inflammatory arthritis to prevent disability. If adequate services are available, people could remain at or return to work while maintaining independence. Effective treatment can greatly reduce the risk of the co-morbidities I noted earlier. Adequate rheumatology services would reduce pressure on primary care, emergency and orthopaedic services.
I will contrast two patients, a mother and a daughter, who suffer from rheumatoid arthritis. Both developed rheumatoid arthritis at approximately the same age, the daughter at her current age of 16 and the mother when she was 19 years old. The features of acute rheumatoid arthritis are apparent on the face of the 16 year old daughter, while the signs of long-established chronic rheumatoid arthritis may be seen in the mother. The daughter is now in clinical remission and treatment is available which will reduce the likelihood of her developing a similar disability as her mother. This is essentially because the daughter had access to a specialist multidisciplinary team within two or three months of her first symptoms. She has access to the best standards of medical care and levels of treatment available and her disease has been successfully brought into remission. This does not happen where inadequate services prevail. Early treatment prevents joint damage and disability and greatly reduces the risk of co-morbidity.
I wish to discuss reasons to develop academic rheumatology. Academic rheumatology will optimise specialist medical and allied professional training. It will ensure excellence at primary care level and will enhance the development of high-quality clinical and basic science research into the prevention, treatment and cure of painful and disabling bone and joint diseases such as chronic arthritis and osteoporosis.
The Department of Health and Children, the HSE and the rheumatology community should work together to create a patient-centred service which will match the best in Europe. The Department of Health and Children, the HSE and the universities and their affiliated teaching hospitals should collaborate to develop a high-quality academic environment which will enable the highest standards of teaching and research on arthritis and related diseases.
We are available to answer questions. As I omitted to raise the issue of waiting list times, I ask my colleague, Professor Oliver Fitzgerald, to elaborate on these figures.
Professor Bresnihan noted some of the waiting times currently obtaining for patients who wish to see a rheumatologist. The waiting time for a patient who requires an urgent first consultation is three to six months. The average waiting time for a routine first consultation is nine to 15 months. The waiting time for a routine return consultation ranges between five months and four years. I will allow Dr. Robert Coughlan to speak on the situation in Galway, which is particularly troublesome.
Since we were last here, it has been confirmed that every patient on the waiting list in Galway wants to be seen. As of 11 May, 871 patients were waiting to be seen in the clinic, 213 patients had waited longer than four years and 244 had waited for between two and four years.
For a first consultation.
For the first consultation. This attests to the inadequacy of the service.
I am sure members have a number of questions but before we begin, I would like clarification on two points. Professor Bresnihan mentioned 12 centres and 19 consultants, which presumably means that some centres have only one consultant, while others have two. Does any centre have more than two?
Professor Bresnihan
Yes.
The component of work that is general medicine as distinct from rheumatology obviously has a bearing on how much rheumatology can do. What is the average proportion of general medicine, 30% or 60%? I know that is difficult to quantify.
Professor Bresnihan
I would say that it is close to 50%.
Not only do we have insufficient services but the work being done is also constricted because of this factor.
Some units have as many as 1,500 general medical admissions per annum through the accident and emergency department. Those patients must be cared for in addition to the commitment to rheumatology. This is a significant commitment.
I wish to clarify that specialists are performing ordinary general medicine.
Professor Bresnihan
Absolutely.
That is a terrible waste.
With the delegation's agreement, questions from members may be answered together.
I thank the delegates for giving this important presentation. The fact that they constitute a large proportion of the total number of rheumatologists speaks for itself. The deficit revealed in the presentation is shocking, particularly in terms of comparisons with Britain and Northern Ireland. Britain has nearly five times Ireland's coverage. The level of investment in the health services here should have brought about a significant improvement in the situation.
The issue of early diagnosis as a preventive measure was raised. May the onset of arthritis be prevented? While the delegation's focus is on service in acute hospitals, do we need more professionals at primary care level? Presumably, a four year waiting time predominantly occurs in certain geographical areas such as Galway, Kerry and the west. Is there capacity to expand the number of consultants and specialists? May they be trained here or must they be sought from abroad? Will difficulties arise as a result of this situation?
It seems obvious that there should be a strategy and questions should be asked on why one is not in place. Has there been any progress in terms of having clear targets to ensure that needs are being met, even if on a phased basis?
I thank the delegates and pay tribute to Arthritis Ireland, which does wonderful work. Services need to be developed and supported across the country. It was significant that the presentation referred to partnerships.
I also welcome the consultant rheumatologists and Ms Mary Healy and others from the arthritis association. I had pushed for their last visit here on 18 September 2003. It was agreed at that time that they would be invited to return within one year. A year and nine months have since passed. I believe that Professor Fitzgerald first suggested that the delegation would return in six months. However, it was decided that it was possible that nothing would have happened in a year, which was prophetic.
I want to get to the nitty gritty of the issue. I also welcome Ms Mary Healy. She has worked extremely hard for arthritis sufferers and has been a strong advocate in highlighting the terrible deprivation suffered by them. Will Ms Healy elaborate on the situation with which people must deal? In Mayo, people get up at 3 a.m. to go to a hospital for an appointment and there they must wait for several hours. This takes place after their perhaps having waited for this appointment for four years. In other words, in Western Health Board areas, some people will not be given an appointment for rheumatology until two years after the next general election. Perhaps that brings the scale of the deprivation home to the politicians present. I have spoken about this before and have highlighted the issue. Basically, the list has been validated and contains 800 people who must wait for four years.
I have examined the map regarding the situation in Galway and a four-year waiting list with 800 people is much longer than in other parts of the country. Dr. Coughlan works hard. The problem is not that he does not work hard and perhaps he should be a professor. However, I am interested in the regional breakdown. Can Dr. Coughlan spell out exactly why such a large number of people in the west are waiting? There are 14,000 arthritic sufferers in Mayo alone, which might be one reason.
What progress has been made since our last meeting? A number of appointments have been made. However, in 1995, Comhairle na nOspidéal made recommendations regarding the required number of rheumatologists, which, as the delegation pointed out, should be one person per 85,000 according to the British Society of Rheumatology. As we have one person per 400,000, little progress had been made in that time. Moreover, a report was made on the issue. Will the delegation provide the joint committee with that report's status?
Another matter which was raised previously is the fact that there is no paediatric rheumatology service in Ireland. Previously the witnesses stated that it needed to be developed as a matter of urgency. What progress has been made?
Without being parochial, we have discussed the need for a unit in Mayo. Ms Healy can confirm the very end of Mayo is approximately the same distance from Galway as Galway is from Dublin. It is as though people in Dublin, having waited for four years for their first appointment, were obliged to go to Galway for it. Will the delegation comment on this? A Mayo unit might help. There is not even a clinic in Mayo, let alone a rheumatology unit. What does the delegation think about this and how might this situation be resolved?
For a long time, I have pointed out that people must queue for years to get on to the waiting list for the national treatment purchase fund. In other words, one must see the consultant first. I understand that the Tánaiste and Minister for Health and Children has announced a pilot scheme in this area. Given that there are so few rheumatologists, is it feasible and is there capacity to see people under the treatment purchase fund? Is there capacity in the private sector? I recognise that while the national treatment purchase fund has done good work, it has simply taken the edge off the situation whereas the ideal is to invest in the services and consultants locally.
The delegation noted that paramedics such as physiotherapists, occupational therapists, special nurses and so on are part of the team. I understand from what the delegation has stated that there is still a shortfall in such staff. Is this because of a lack of resources or a scarcity of personnel?
Professor Bresnihan
Deputy McManus raised the question as to whether anything can be done to prevent arthritis from happening. At this point, with most of the severe forms of arthritis, it cannot. Our current state of knowledge does not permit us to stop the development of rheumatoid arthritis in someone who is susceptible to it. There are various occupation-related disorders which better occupational facilities might reduce or prevent from developing into osteoarthritis. The issue of primary care and undergraduate teaching is important. I can speak for UCD and others on the panel can speak for other teaching hospitals and medical schools. Little rheumatology teaching is provided at an undergraduate level. In fact, many medical students graduate from medical school without ever having been attached to a rheumatology team. Hence, there is a great need to improve access to rheumatology on the medical undergraduate curriculum.
A question was raised concerning capacity and whether there were sufficient rheumatologists to provide a service. We now have a specialist training programme in place in this country and it produces excellent specialists. Given the infrequency of job appointments, many of them are obliged to go abroad, which is a good thing because it widens their experience. However, we are fortunate in that for every consultant job which comes up for interview, we get superb candidates from the United States, Europe and the United Kingdom who wish to return to Ireland. The jobs would be predominantly filled by Irish graduates.
I will hand the question regarding progress with the strategy to Professor Fitzgerald. I will hand the Galway and Mayo questions to Dr. Coughlan. As far as paediatric rheumatology is concerned, the first appointment in the country has been made. It is a joint appointment between Our Lady's Hospital for Sick Children in Crumlin and St. Vincent's Hospital. The appointee will take up her appointment in July 2006, which is a start for paediatric rheumatology. I will not attempt to answer the questions regarding the national treatment purchase fund myself. As to the question regarding allied health professionals, they have begun to develop seriously in recent years. Although they are somewhat behind the training of the medical specialists, great strides have been made. For example, there are higher diplomas in rheumatology nursing and, increasingly, postgraduate opportunities are becoming available to graduates in physiotherapy and occupational therapy. Hence, important advances are taking place but more must be done.
As far as the current position with regard to the strategy is concerned, we met the Tánaiste and Minister for Health and Children, Deputy Harney, earlier this year. It was a very positive meeting. A delegation similar to this one represented the arthritis community. She gave us much of her time. Following that meeting, a letter was sent to the Health Service Executive in which she stated she was favourably disposed to the development of rheumatology. Earlier this week, we met a representative of the HSE for the first time. It has agreed to engage with us to examine the emergency situations throughout the country and also to develop a more long-term strategy, which I view as a positive development. It will be a long process but is the way forward. I am delighted to hear it will happen.
As far as the national treatment purchase fund is concerned, it will be very difficult. The money would be better spent in the rheumatology services. The existing rheumatology consultants already have lengthy waiting lists for private appointments. Speaking to my colleagues around the table here, I found no one with a waiting list of less than six months. It will not be easy to deal with patients on an outpatient waiting list through the national treatment purchase fund.
Another question concerned the situation regarding people who are obliged to travel long distances. Ms Healy is here from Mayo. Another question related to the regional situation as regards Galway.
Deputy Cowley is from Mayo.
Professor Bresnihan
Perhaps Ms Healy and Dr. Coughlan could answer some of those questions.
I am delighted to have the opportunity to represent Arthritis Ireland and people with arthritis. I also represent people from other branches who are in the Visitors Gallery. I was diagnosed with rheumatoid arthritis and waited 18 months before I was examined by a rheumatologist, by which time my fingers had begun to show signs of damage. Members of the committee can see the damage that has been done over the years. By the time I was examined by a rheumatologist, I needed surgery on my foot. I have had surgery carried out on my feet and toes and two knee replacements. I also face impending surgery.
Regarding Deputy Cowley's question about the reason so many people are on waiting lists, from a Mayo perspective, we have an ageing population. Given that the majority of people over the age of 65 show signs of joint disease, they will depend greatly on health services in future. We need to tackle this problem now because, from an economic perspective, there will be considerably more pressure on the health service if something is not done now. Early intervention is important to prevent damage such as that which I suffered.
As there is no rheumatology unit in the hospital in Mayo, some of those seeking to access the medical services and treatment at Merlin Park Hospital in Galway will have to get up at 4 a.m. to travel there. This can be very difficult for someone in pain. Sitting in a car for four hours and then sitting in a clinic for four to five hours can be very painful; I have been forced to do this myself. The clinic in Merlin Park Hospital sometimes does not finish until 7 p.m. Not only does this situation put terrible pressure on patients and their families, it also puts terrible pressure on Dr. Coughlan and his team.
When some people do not have access to their own transport, they are forced to take public transport to Galway, which is very difficult for someone with arthritis and who is in pain. People from Belmullet, which is one of the furthest points in Mayo which is a sprawling county, have to take a bus to Castlebar, get another bus to Galway city and get another bus to Merlin Park Hospital. They then have to wait at the hospital for possibly three to five hours to be seen and hope that they do not miss their bus home. This is an intolerable situation for people in pain and should not be allowed to continue. Arthritis is a major health problem in Ireland and needs to be tackled now. I know some people who are forced to take their children out of school to travel to Galway because they would not get back to the school in time to collect them.
In addition to the shortage of rheumatologists, the country faces a shortage of physiotherapists, occupational therapists and rheumatology nurse specialists who have a very important part to play in the treatment of people with arthritis. This is an area that must be tackled. If people are to maintain their independence and mobility, they need access to physiotherapy and occupational therapy. I have spoken to people who are suicidal, and I do not use this word lightly. These people contact the Mayo branch of Arthritis Ireland and tell us how badly they feel about the fact that they must wait four to five years to be seen by a consultant for the first time for a condition that causes them so much pain. They are people who are unable to sleep owing to the pain they experience, whose quality of life has changed and who have been forced to give up their jobs owing to their arthritis. There are 213 people still waiting four to five years to be seen by a consultant. This is intolerable and should not be allowed to continue.
I ask for the committee's support to improve rheumatology services and rheumatology teams in order that we can move forward and allow people with arthritis to lead productive lives. Arthritis is a very treatable disease. There are many high-tech drugs which can be used in the early stages of the disease to prevent permanent damage to joints. Let us hope people on waiting lists throughout the country will be able to access these drugs. There is little point in having high-tech drugs if people with arthritis are unable to access them.
I thank Ms Healy. That was a very moving account from someone who has the disease.
We have very long waiting lists in the west and there are long waiting lists elsewhere in the country. The situation in the west has been highlighted here today. There are unacceptably long waiting lists in all centres but the waiting list in Galway is completely unacceptable. Our service is running at approximately twice its recognised capacity. If one looks at the map, one can see that there is no rheumatology centre between Dublin and Galway. We treat patients from Belmullet in the north to Carrigaholt in the south and across to Athlone.
It is extremely difficult to witness the joint damage that has occurred in patients who have waited two or three years for an appointment with a consultant. It is clear that this joint damage has occurred while they have been waiting for an appointment. It is very distressing to witness this and although we try to identify people who will suffer joint damage if they are not seen immediately, sometimes one can miss them. A considerable amount of disability is caused while people wait to be seen. Those individuals who shout loudest are sometimes seen quickest. Sometimes, this is for a good reason but ordinary people who recognise that there are limited resources often decide to wait their turn and suffer as a consequence. It is a very distressing thing to happen and for us to see.
I too welcome the speakers and thank them for their submissions. Dr. Coughlan's presentation was short but very comprehensive and highlighted the difficulties. I understand that there is one rheumatologist for every 20,000 patients. Twenty rheumatologists for 400,000 people translates into one rheumatologist for 20,000 patients. Assuming that one rheumatologist can deal with 200 patients on an ongoing basis, only 10% of the 400,000 people who need treatment receive it. Is my interpretation correct?
Professor Bresnihan
Not every person with joint disease needs to see a specialist. Approximately 60% of patients with arthritis can be managed effectively at primary care level. That might alter the figures but it does not surprise me that the statistics produced by Deputy Neville are difficult to believe.
Very little research is carried out in Ireland. Professor Bresnihan quoted figures from the UK. Can he comment on why the level of interest nationally or on a departmental basis is so low?
Professor Bresnihan
The figures are not being collected. It is very difficult to get figures from the Department of Health and Children, for example, because often they are not available because they are not being collected.
Why is that the case? For a Department to understand the extent of any problem, it must know the figures involved.
Is that the figure for treatments?
No. These are the numbers of people with arthritis, which are extrapolated from the UK's figures since Ireland does not have figures of its own. No research has been carried out and the Department has not determined the extent of the problem in Ireland. The best it can do is to generalise from the UK's figures, which suggests this issue is a fairly low priority for the Department.
The hospital inpatient enquiry system, HIPE, captures inpatient, not outpatient, activity. This system captures data about inpatient waiting lists, treatments and so on.
Is there any research in the outpatient area?
We do not have information on outpatients as there is no collection of data in that area.
That would reflect the priorities viewed by the Department. In view of the fact that our guests are generalists as well as specialists, how do they operate multidisciplinary teams? I examined such teams in another area but it must be almost impossible to have a dedicated team if one is both a generalist and a specialist. The visitors have presented this to the committee as operating. How does it operate if there is no multidisciplinary team dedicated in the way the visitors have mentioned? A developing feature of the health system as a whole, and not just in Professor Fitzgerald's area, relates to inquiries into waiting lists for private patients. What is the difference between the waiting times for public and private patients?
Deputy Cowley spoke about County Mayo at considerable length.
The Deputy must——
The visitors said that there is a service developing in Limerick. At what stage is this service and what progress has been made? When will a full service be available?
Professor Bresnihan
I will answer the easy question on Limerick. A position was funded approximately one year ago and an appointment has been made. The person appointed has not yet taken up the job, which is extremely difficult as service must be provided at four centres. The Limerick regional hospital will be the base centre but the person must also provide some level of service at Croom, Nenagh and Ennis. I imagine the person will spend a significant amount of time driving.
Has a multidisciplinary team been developed for this?
Professor Bresnihan
The appointee must begin that exhausting process upon arriving in Limerick.
Dr. Michael Molloy
I will address the geographical sweep in the south and south west. I work in University College Hospital, Cork and cover the Kerry and Cork areas. To give the committee an idea about the distances involved, as someone did earlier, by the time one reaches Mallow from Castletownbere, one is half way to Dublin. The territory is large.
It is.
Dr. Molloy
We also provide a service for Tralee General Hospital but it should have its own rheumatologist because there is adequate work for one. There are two other rheumatologists in Cork. It is not with pride I say that our waiting list has approximately 1,200 or 1,300 patients on it. It is important to realise that if a general practitioner has a patient with inflammatory arthritis about whom he or she is concerned, he or she will ring us. We are now revalidating our list for these patients, many of whom do not have serious inflammatory arthritis as described here. They will be sent to us directly by their general practitioners, a number of whom are present and understand how the system works. However, a large number of patients must wait, which is a problem. After our previous meeting on the emergency package that came from the good work of Professor Fitzgerald, we got another position in Cork. Someone has already been appointed and will take up the post in August. I understand there is a possibility of another such position in Galway. However, we are only touching the margins because this is a major problem.
On the Deputy's questions about the mix with general medicine, we spoke about training people. One of our advantages from being involved in general medicine is that we have very high quality junior doctors in our hospitals. They train for three months with us and learn a great deal about rheumatology in that time. Many of them enter general practice after their training. From all our points of view, we must work in the major and peripheral teaching hospitals where our colleagues expect us to take a share of the general medicines work. This is not an ideal situation and I do not believe it will change. If one examines smaller hospitals, it is critical that all of the new physicians coming on board carry out their share of acute medicine work as well as concentrating on their specialties. Our trainees are all duly trained and certified in internal medicine and rheumatology. We intend to continue this system.
That is against the view of most other specialists, who all now want their work specialised. The approach was more generalist than specialist 20 years ago.
Dr. Molloy
This is a matter of sharing the large acute medicine workload. The more people who do it, the easier it is to share. In all the hospitals I know of that have new positions, the appointees will be doing general medicine as well. Their colleagues will insist on it as their colleagues are also specialists in their own fields. We have an emergency package to help us but we must examine the long-term position. We have better treatments available now that will make these patients' lives better.
Dr. Gaye Cunanne
Rheumatology is a cheap specialty because we do not use expensive equipment. As Professor Bresnihan said, if we see patients early, we can sometimes get them into remission by using some of the most inexpensive drugs. The specialty becomes expensive when patients do not go into remission. They develop joint damage, cancer, heart disease, osteoporosis, etc. Solving the problem early is critical and it is a solvable problem. We are a group of highly motivated people who all wish to solve the problem.
Deputy McManus mentioned issues concerning GPs. There are shared care protocols whereby rheumatologists can co-operate with GPs in terms of teaching them joint injections or talking about the disease-modifying drugs we use. If there were more rheumatologists, it would be much easier to establish this sort of protocol. When we speak about resources, we are not only speaking about the numbers of consultant rheumatologists but also about the resources — nurse specialists, physiotherapists, occupational therapists, etc. — to accompany them. When I was appointed over two years ago, I got nothing. At St. James's Hospital, there is no full-time physiotherapist, occupational therapist or nurse specialist for our field.
The national treatment purchase fund has mainly benefited surgical patients but some of those funds could be released to deal with public waiting lists and not just private waiting lists. If we had nurse specialists and more junior staff and locum consultant rheumatologists, all of the waiting lists throughout the country would benefit without any interference in private waiting lists or the creation of a dichotomy that would make everyone feel uncomfortable.
What is meant by the reference to the national treatment purchase fund? Should money be released to fund a locum post?
Dr. Cunnane
For example, funds might be released to allow a locum consultant to conduct several sessions per week for each hospital with a long waiting list, including secretarial help, physiotherapy help, etc. This would improve the situation.
That is an interesting concept.
I wish to comment on the lengthy private waiting lists. Many patients cannot access the public waiting list. They have low incomes, as indicated by their possession of medical cards, and some must borrow money to attend private rheumatologists or to have surgery. The private waiting list is growing due to the inclusion of the many medical card holders who are unable to access the public waiting lists in their areas.
I welcome the delegation, particularly Professor Bresnihan as he is the man who rebuilt my mother. She would not like me to describe the process in that way but he did give her back her life. I compliment him on his succinct presentation. Are people in Ireland more prone to arthritis? Will Professor Bresnihan explain what causes the disease? He mentioned that some people are more prone to rheumatoid arthritis. What are the traits that make an individual more susceptible to it? What is the early intervention that can prevent the onset of arthritis? Is it physiotherapy? Dr. Cunanne mentioned that the drugs and equipment are not expensive. One would have imagined that would not be the case. Does the treatment involve massaging and to what kind of equipment was she referring? What has been the impact of the recent removal of these drugs from the market?
When one looks at the map of Ireland, one sees gaps in the provision of service. Does the delegation have any idea where a new centre should be placed or how far away one centre should be from another? Perhaps the delegation does not have statistics for Northern Ireland. Does it have any idea of the effect of the better service available in Northern Ireland?
It is interesting that once a consultant is appointed, support services do not necessarily follow.
I apologise, there is a vote in the House. We will be obliged to suspend for 15 minutes. Perhaps Deputy Fiona O'Malley could finish her question briefly before we do so.
As it was a very interesting presentation, I have a few questions.
I welcome the delegation and as a former chairman of a health board, I hope that we did something to improve the situation in the west. If we did not do so, we failed.
I apologise for arriving late. Unfortunately, I must now leave again.
Deputy Fiona O'Malley has some further questions for the panel.
I presume note has been taken of my previous questions.
I am interested in the rheumatology centres and the package of treatment available there. There seems to be quite a period between an initial appointment being made and the commencement of treatment. Must rheumatology services always have a consultant rheumatologist or would it be possible in areas such as Athlone, the Midlands or Mayo, where there is no centre, to have the other support services in place to provide treatment for patients in pain? The panel has argued that a consultant must be appointed before a rheumatology centre can develop but I believe it would be possible to develop a service in the absence of a consultant. If one takes Limerick, for example, the consultant will spend much of his or her time travelling around. Does Croom have a rheumatologist?
It had a rheumatologist in the past.
No, there was never a rheumatologist in Croom.
It may be preferable to have a consultant in a rheumatology centre but it is not an absolute necessity.
The public believes that the national treatment purchase fund is successful. The description of the fund by the panel was slightly misleading because patients waiting more than three months, particularly those on public waiting lists, will receive treatment soon. Do members of the panel refer their patients to the national treatment purchase fund? It is only when a consultant refer patients to it that the fund can be of assistance.
The panel gave us some case histories and it is frightening to think that a 16 year old could suffer with such severe arthritis. The young woman in question is now in remission but I presume that she will need constant care. How costly is that care and what would be the cost if she did not receive it? The mother of the woman in question has extremely severe arthritis. Will it be possible to prevent her own condition from becoming as severe as her mother's and what would be involved in that regard?
To what extent is research being carried out on arthritis in Ireland? My mother, who suffered from the condition, made me aware that there is very little international research done on arthritis because it is not a high profile disease. The assumption is that it only affects older people and that it is a part of the normal ageing process. Would the panel agree with that analysis? Could members of the panel outline research developments, particularly as they relate to preventative treatments?
I welcome the delegation. Appearances before committees of the Oireachtas are very important. This is particularly true of this committee in the post-health board era because there is a now gap between the public representatives and health service administrators and providers.
I served on health boards from 1994 and I was the founding chairman of the South Western Area Health Board. I am aware of the work being carried out by some members of the panel but I am not familiar with the situation in Cork and Galway. On these occasions I would not normally be parochial but Mayo, Limerick and Cork have been mentioned frequently and Professor Fitzgerald referred to the geographical spread of services, so I will refer to Dublin at this point. It may be obvious from my accent that I am from Dublin. I was born within sight of Leinster House. I live within sight of Tallaght Hospital and my home is near the Luas line, which passes St. James's Hospital. This background information will enable the panel to see where I am coming from.
Where is the Deputy going?
I represent Dublin South West, which embraces the major population centre of Tallaght. My motives will be clear by now. I wish to argue the case for Dublin, while not disagreeing with anything that has been said about the other rheumatology centres in the country. It is important that we stress the need to develop our services and Ms. Healy clearly outlined the challenges posed by arthritis. It appears that each centre is competing with the other for a slice of the health pie. Many groups come before this committee to make the case for additional funding and I receive many representations from consultants at Tallaght Hospital and St. James's Hospital.
I am interested in the development of rheumatology services in the Dublin region. I am aware that the appointment of a consultant for Tallaght Hospital is pending. It is important to recognise that sick people are awaiting treatment. The latter applies to the rheumatology service as well as to health services in general. I am happy to speak as a Government backbencher. Despite claims by my colleagues in the Opposition, Government backbenchers have an important contribution to make to this debate. I am never afraid to note difficulties. Not only am I a public representative for Tallaght but I was also proud to be a patient of Tallaght Hospital. Thankfully I am now well.
My experiences have given me reasons to support the work being carried out. Deputy Fiona O'Malley made reference to her mother. My father, who was a long-term patient of St. James's Hospital also had serious difficulties with arthritis. One's experiences are brought to politics and other facets of life. My own opinions are based upon information from my constituents, what I see and the sufferings of my family. I am not afraid to express my support for the actions being taken by this delegation. It is important that public representatives support these actions.
While I have no problem with discussions of rural areas, I have particular interest in the development of services for Dublin. It is important that we invite groups here. We should maintain pressure where these issues are concerned. I am sensitive to the views of delegations before this committee who wonder about the progress made in the three years since their previous visit. This committee should be able, if issues are brought to its attention, to find a resolution within six months or one year so further issues may be addressed. What specific actions would this delegation ask the committee to take on this matter?
Assuming that 50% of rheumatology specialists' time is spent on general work, they would double the numbers of patients treated if they were to work full time. I ask that this be put in context. Does the delegation have an opinion on the insistence of the Department of Health and Children that contracts be general rather than specific consultancy based?
Professor Bresnihan
I shall answer the last question posed by Deputy Neville because earlier questions tend to fade from memory.
I shall mention Dublin again.
Professor Bresnihan
I do not know the answer to Deputy Neville's question. An easy answer is that many consultant appointments in Ireland across specialties are joint appointments, where consultants are charged with a share of acute general medicine in addition to their specialties. Debate and revision is needed on this practice.
The Deputy asked whether, if we were to shed some of the acute general medicine load, we could double the number of patients treated. This is probably true but we should also increase the quality of care which we give to patients already being seen and develop other aspects of our specialty, including teaching and research activities. Time is needed to address the significant deficiencies that exist in terms of teaching. My priorities, if I was able to shed some of my general medicine responsibilities, would include teaching as well as research activities.
People in Ireland are probably no more susceptible to arthritis than other countries. Arthritis is as significant in California as in Ireland. The influence of climate and dampness is mythical. There is no reason to expect that Ireland has more cases of arthritis than the UK or that Irish figures are different. It is important to have our own figures but there is no reason to expect that statistics would be different in Ireland.
Deputy Fiona O'Malley asked about comparisons with Northern Ireland. While direct comparisons have not been made, I expect that there is a difference in the quality of care because patients there do not have to wait as long to see a specialist. This must have implications for patients' quality of care and life.
I do not believe it workable to develop centres without consultants. The universal model is that sub-specialties are led by consultants, who are trained to lead multidisciplinary teams in the practice of the relevant specialty. A trained consultant would be required to provide a level of excellence. Arthritis is not simple. Patients may face many complications and many forms of arthritis exist. Even as an experienced consultant, I daily learn of new matters. It is important that experienced and well-trained consultants lead centres. When a new consultant appointment is made in, for example, Limerick or Castlebar, it should be anticipated that the consultant will need a multidisciplinary team. It is illogical to make an appointment to Castlebar without provision of the support needed for excellence in patient care.
Is it the case that if there is not a consultant in Castlebar, the remainder of the multidisciplinary team is also not in place? Does a similar situation apply throughout the country?
Professor Bresnihan
A consultant is necessary to lead the service.
Dr. Cunanne
When a consultant is appointed, he or she does not necessarily arrive with the relevant resources. Negotiations on their provision can take a significant period of time. I have been in St. James's Hospital for more than two years and have not yet succeeded in achieving the necessary resources.
Professor Bresnihan
Research is fundamental to good quality clinical care. There must be an an inquiring environment in which people ask questions about the diseases being treated and the gaps in knowledge. The research environments in some of the centres in Ireland are active and productive but need to be developed in others. The development of research is critical to raising standards in clinical care. Many issues are entirely local and require a better understanding. The research environment is quite healthy but needs to be developed.
Are the research centres based in the three university cities of Galway, Cork and Dublin?
Professor Bresnihan
Most of the activity takes place around teaching hospitals and active medical schools.
Is that where Professor Bresnihan sees future developments?
Professor Bresnihan
Logically, if academic departments of rheumatology are to be developed, they should be associated with university medical schools. I thank Deputy O'Connor for his positive comments and agree with him that Dublin needs to be developed.
Dublin should be put on the map.
I will address some of the questions raised earlier. Deputy Fiona O'Malley asked where the centres should be sited. The Irish Society for Rheumatology produced a manpower document which I believe was seen by the joint committee the last time we appeared before it in 2003. Among the emergency recommendations were recommendations as to where exactly the centres should be sited. Some of these issues and deficiencies have been addressed in the intervening period, but there are still major black spots in the country. Some consultants still struggle on as single-handed consultants. Some areas must be addressed. For example, there is no service whatsoever within the former Midland Health Board area.
Professor Bresnihan has already commented on this, but it is worth pointing out that the figures for rheumatologists in Northern Ireland are the worst in the UK. Overall, the UK figures are much better and I believe figures closer to one in 100,000 are the average there. If we use Northern Ireland as our benchmark, we should be aware that it is the worst in the UK.
I do not have any hang-ups about the national treatment purchase fund. I agree it has worked well. However, it is confined to inpatient treatment and we are discussing outpatients at this meeting. We have met representatives from the national treatment purchase fund. The Irish Society for Rheumatology met them to discuss how the fund might be applied to outpatient rheumatology waiting lists. I believe that was approximately one year or 18 months ago. Dr. Coughlan was also present. At that time, they were not willing to address outpatient waiting lists.
The announcement yesterday from the Minister is certainly to be welcomed. However, the idea of the existing consultants being asked to see more patients in their private capacity will not work, because they already have waiting lists stretching six months or more. I agree with Dr. Cunnane's point that the only way to address this is to recruit additional people.
As far as Deputy O'Connor's questions regarding Dublin and Tallaght are concerned, Dublin has not been highlighted. Cork and Galway have been because their waiting lists are far longer. However, just because the waiting lists in Cork and Galway are far longer does not make it acceptable that patients in the Dublin area must wait six months, 18 months or two years, depending on the unit. It is completely unacceptable that patients who are still in pain are obliged to wait that long. As of approximately two weeks ago, the first full-time rheumatologist has been appointed in Tallaght, which is good news.
We will be delighted to return in one year to report on progress. Given that we finally made a connection recently with the HSE, I hope we will have something positive to report in one year. However, we must wait and see. If we could name a specific initiative on which we would like the Tánaiste and Minister for Health and Children to sign off and sign a cheque, we would all be lifted if she approved the first academic chair in rheumatology and provided at least partial funding for it. A provision to kick-start that process would be enormously helpful.
On the question of the national treatment purchase fund, rheumatology is not a specialty that lends itself to its model of spending money, in that we do not, for example, perform operations on hernias which have a beginning, a middle and an end. Many of the patients we see will go on and on. The national treatment purchase fund could consider providing funding in a hospital for a rheumatologist for four or five years where it is obvious that more rheumatology consultants are required. It could kick-start that appointment by funding it for five years, in the expectation that the HSE would take over the funding after a number of years. In that way, the national treatment purchase fund could address the question of waiting lists in a way that joins up with the health service, rather than removing patients. One cannot take them anywhere. One cannot send a rheumatology patient to England and expect that he or she will get treatment and that the expenditure will be finite. One cannot expect someone to be seen by a private rheumatologist and at the end of a defined period to return to the health service, where one does not have——
Are people not treated for joint replacements on the national treatment purchase fund?
Yes. However, that is a finite procedure.
Yes.
That is my point. We do not have a——
This is the problem when one is not an expert.
We do not have a beginning, a middle and an end. We are endless.
Dr. Molloy
Professor Fitzgerald touched on the HIPE scheme, the hospital inpatient enquiry scheme. This deals with inpatients only. Frequently, when the Department of Health and Children looks at its budgets, it uses this as its measure of activity in a specialty. As has been made clear today, we are mainly an outpatient specialty. Therefore we do not have activity recorded. We have our own figures. While Professor Fitzgerald was possibly too modest to mention it, despite the general medical input, we see a large number of patients. On an international scale, we see more than we should. It is important to realise that the Department of Health and Children will only take an outpatient service like ours seriously if we actually record it and the Department gives us credit it for it.
It is important to mention that the newer preparations and drugs in rheumatology are very expensive. They are highly effective and are economically accepted in most countries, but are expensive. In the future, we will have a better opportunity to treat our patients early and successfully.
I was intrigued by Dr. Cunnane's comments. I hope I understood her point. Am I to understand that we appoint consultants without implementing proper support structures?
Dr. Cunnane
The Deputy understands correctly.
Does this take place right across the board, not only in rheumatology?
Dr. Cunnane
Right across the board. That is correct.
This committee has always been led to believe that a consultant costs X euro, but in terms of the position and its support staff, the cost is something like €1 million per consultant. However, the reality is that only the consultant is appointed.
Dr. Cunnane
It depends, but it is quite common for a consultant to arrive with no office, no secretary and absolutely no support staff and then to initiate negotiations in order to secure them, while at the same time carrying out his or her general medical duties and clinics.
This is unacceptable.
I am trying to grasp this. When a consultancy post is advertised, surely some specifics go with it. When one applies for a post, one is told what one will receive and is given an indication of the support structures that will be in place to facilitate doing one's work.
Dr. Cunnane
No.
All one gets is the job.
Dr. Cunnane
That is correct.
Is this across all disciplines or just in rheumatology?
Dr. Cunnane
It is across all disciplines, but it varies.
Does it vary between health boards?
Yes. Some new consultant appointments are made in departments which are already established and where the infrastructure is already in place. The manpower might go from three consultants to four. However, for many of the new appointments which we are discussing such as the consultant returning to Tallaght or Dr. Cunnane's appointment to St. James's, there is nothing in place. It is a new appointment and nothing is in place to support it.
Not even office space.
Nor a secretary. One is on one's own.
It is a waste of resources to appoint a consultant without the support.
Sometimes there are no outpatient facilities. People have suggested that if one gets rid of general medicine, one can double the number of patients seen. The problem is that one does not have the outpatient facilities in which to see them. New appointments are being made. However, I can give an example of a surgeon who was appointed recently to St. Vincent's. When he was appointed, there were no outpatient facilities or theatre space available. What is he to do?
As an observation, one of the basic requirements from management is planning. We have a dearth of managers in the Health Service Executive regions. There is no planning.
I asked this question earlier. My point concerns the lack of paramedics. When Dr. Cunnane was appointed, she did not have the appropriate number of paramedics. Therefore it is a question of resources rather than recruitment.
Dr. Molloy mentioned new drugs and how important they are. I worked in the field of rheumatology and nothing has changed in the years since I left the unit. Dr. Coughlan has just replaced Dr. Donnelly — that is the only change. On the other hand, the population has grown dramatically. I suppose the priority must be to appoint another consultant to work with Dr. Coughlan.
I used cytotoxic drugs when I worked for Dr. Coughlan's predecessor. They are very effective but, as Ms Healy noted, it is a question of getting access to them. If one has to wait four years to be treated with them, one's joints will have been irreparably damaged and the opportunity for the drugs to work will have been lost. Do doctors face pressure not to prescribe these drugs? If a person gets to see a consultant, will he or she be prescribed those drugs or is there pressure not to prescribe them? I am not suggesting that the doctors here would not prescribe these drugs. I am merely asking whether there is a problem concerning their availability.
Dr. Molloy
There is no problem whatsoever. We have a package with the new consultants which includes paramedics but they cannot be appointed until the Health Service Executive gives us permission to break the whole-time equivalent ceiling. Plenty of jobs are funded but they cannot be filled until the Department of Health clears the whole-time equivalent ceiling. The ceiling means that no more people can be appointed. Appointing somebody new means dropping somebody from another department or somebody retiring. Getting people appointed is a major problem because of the ceiling on whole-time equivalents, even if the funding is in place.
Does Dr. Cunnane wish to say anything about the drugs issue?
Dr. Cunnane
There is no problem prescribing some of the high-tech drugs that are administered by subcutaneous injection by patients themselves. However, there is a problem getting access to Remicaid, which is an inpatient infusion.
Where does the problem lie?
Dr. Cunnane
The problem lies in the fact that it costs the hospital or health board money when it is administered in the hospital.
Would it not possibly save the patient's joints from being irreparably damaged?
Dr. Cunnane
That is correct.
Does the problem lie in the effect on the hospitals' total budget or does it lie with the Health Service Executive?
Dr. Cunnane
It is a budget problem.
Is it a budget problem in the hospital or the Health Service Executive?
Dr. Cunnane
It is a budget problem in the hospital.
Why should that be? Why should budget considerations decide whether somebody's joints are saved? Why should somebody be left with a lifetime of irreparable damage to his or her joints because the budget will not stand up to it?
Dr. Cunnane
Deputy Cowley is right.
Is it because it needs to be medically administered in a hospital?
Dr. Cunnane
Yes, that is correct.
That is something that this committee should immediately straighten out. The committee should ensure that this drug is made available to people who need it because otherwise they are left with irreparably damaged joints.
The Department of Health and Children needs to examine carrying out a programme of voluntary redundancies to allow for new appointments. Would Dr. Cunnane recommend that support teams be provided for existing consultants rather than new consultants appointed? It appears to me that if a consultant is appointed in Castlebar, he or she will be unable to provide a service and will be left with little to do. From a patient's perspective, it appears that it is better to provide the support services rather than appoint a new consultant who cannot do anything for patients. Would Dr. Cunnane agree with me?
Dr. Cunnane
No, we need both support teams and new consultants.
In the absence of being able to provide both, would it not be better to provide support teams? I suppose one does not want to recommend not appointing a consultant.
We need both support teams and new consultants.
Dr. Molloy
We have clinical responsibilities. Who takes clinical responsibility for the patient?
Dr. Cunnane
The consultant is leading the service and is able to produce a strategy in a way that the health professionals may not be able to.
Is it agreed that the delegation should appear before the committee again in a year's time to report progress?
I will mention that now. I would like to thank the consultant rheumatologists and Arthritis Ireland for giving the committee such an informative and comprehensive presentation. They can be assured that the needs of the rheumatology services are a priority for this committee. In that regard, I have put two recommendations to the committee. The first recommendation is that it should send a full transcript of this meeting to the Tánaiste and Minister for Health and Children outlining all the issues that have been raised. The second recommendation is that it should invite the participants at today's meeting back to another meeting of the committee possibly in a year's time to find out what progress has been made.
The joint committee adjourned at 11.35 a.m. until 9.30 a.m. on Thursday, 9 June 2005.